Provider Demographics
NPI:1265439525
Name:CANYON STATE ANESTHESIOLOGISTS PC
Entity type:Organization
Organization Name:CANYON STATE ANESTHESIOLOGISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPPULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-421-1014
Mailing Address - Street 1:8102 E MCDOWELL RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-3809
Mailing Address - Country:US
Mailing Address - Phone:480-421-1014
Mailing Address - Fax:480-421-9697
Practice Address - Street 1:8102 E MCDOWELL RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3809
Practice Address - Country:US
Practice Address - Phone:480-421-1014
Practice Address - Fax:480-421-9697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCKFCMedicare PIN